HESI COMPREHENSIVE 1 124 QUESTIONS AND
ANSWERS LATEST VERSION WITH GREAT
RATIONALES GRADED A+
A client is receiving atenolol (Tenormin) 25 mg PO after a MI. The nurse determines the client's apical pulse is 65 bpm. What
action should the nurse implement next? -
✔️Administer the medication
Apical pulse is >60 bpm
The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? -
✔️Hyperthyroidism
enlargement of the thyroid gland (AKA goiter). Bruit may be auscultated d/t increase in glandular vascularity which increases as
it becomes hyperactive.
A 6-year-old child is alert by quiet when brought the the ER with periorbital ecchymosis and ecchymosis behind the ears. The
nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture.
What assessment finding would be consistent with a basilar skull fracture? -
✔️Rhinorrhoea or otorrhoea with Halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ears over mastoid process) are both signs of a
basilar skill fracture. Nurse should assess possible meningeal tear that manifest as a Halo sign with CSF leakage from ears or
nose.
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines
the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent
with which disorder? -
✔️Grave's Disease
Aka hyperthyroidism; an autoimmune condition
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than
the right eyelid. Which description should the nurse use to document this finding? -
✔️Ptosis on the left eyelid
Ptosis = eyelid droop covering large portion of the iris. May result from oculomotor nerve or eyelid muscle disorder.
The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight
on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse
take? -
✔️Question the type and quantity of foods eaten in a typical day
Daily diet needs to be assessed because child is overweight
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should
the nurse take? -
✔️Withhold the medication and contact the healthcare provider
bradycardia is an early sign of digoxin toxicity. Infant HR <100 bpm, then withhold med and notify HCP.
The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?
-
✔️Wear the brace over a t-shirt 23 hours per day
Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Milwaukee brace places pressure
against the lateral spine curvature, under the neck, and against the iliac crest. Wear 23 hrs/day over t-shirt which reduces
friction and chafing.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to
wear a gown and mask when you are in my room?" How should the nurse respond? -
✔️"To protect you because you can get an infection very easily"
Reverse isolation precaution implement measures to protect the client from exposure to microorganism from others.
The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which
statement by a parent indicates understanding of phototherapy? -
✔️"I will keep the baby's eyes covered when the baby is under the light"
Neonatal jaundice is r/t subq deposition of fat-soluable (indirect) bilirubin, which is converted to a water-soluble form when the
skin is exposed to an ultraviolet light, so the infants eyes should be protected by closing the eyes and placing patches over
them before placing the baby under the light source.
, HESI COMPREHENSIVE 1 124 QUESTIONS AND
ANSWERS LATEST VERSION WITH GREAT
RATIONALES GRADED A+
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry
mouth. Which action should the nurse implement? -
✔️Apply a water-soluble lubricant to the lips, oral mucosa and nares.
Will ease discomfort and keep the mucous membranes moist.
Petroleum-based is flammable DO NOT USE
The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings
are consistent with the client's clinical picture? -
✔️Serum potassium of 5.5 mEq and total calcium of 6 mg/dl
In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vit d, calcium absorption is
impaired, and serum calcium decreasesm which stimulates release of PTH causing resorption of calcium and phosphate from
the bone.
Which information should the nurse give a client with chronic kidney disease (CKD)? -
✔️Avoid salt substitutes
CKD pts should restrict sodium & potassium intake. Salt substitutes usually contain potassium (so, avoid!)
A nurse is anwsering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to
explain the use of tamoxifen (Nolvadex). Which response should the nurse provide? -
✔️This anti-estrogen drug inhibits malignancy growth
tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit
the growth-stimulating effects of estrogen by blocking their receptor sites on malignant cells. Use for women with estrogen
receptor-positive breast cancer (not all women)
A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for
this client? -
✔️A nurse with Marfan's syndrome who is postmenopausal
Poses a radiation hazard while source is in place. Marfan's is not effected. Goal is to limit any one staff member's exposure to
the calculated time span based on the half-life of radium, such as the number of minutes at the bedside per day
Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer? -
✔️Use a sanitary napkin instead of a tampon
Avoid use of tampons for 3-6 weeks after procedure to reduce risk of infection. Heavy watery vaginal discharge is expected.
Avoid sex up to 6 weeks
Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between
healthcare providers? -
✔️Case Manager
role is to assist the continuum of care for the client, & coordinate the plan of care, evaluate client needs & collaborate with
interdisciplinary HC team to ensure goals are met, quality is maintained, and progress toward discharge is made.
The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the HCP? -
✔️Recalls drinking a glass of juice after midnight
Risk of aspiration while under GA is increased when stomach is not empty prior to surgical procedure.
The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to
"grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing
behaviors. Which information is best for the nurse to provide? -
✔️Early adolescence is a developmental state of normal experimentation
Support parents about the stage spurred by hormonal increases in pubescence and teenage experimentation with values,
choices, and peer acceptance.
The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the
questions for the client. Which action is best for the nurse to implement? -
✔️Ask the spouse to step out for a few minutes
this maintains the client's privacy and allows the client to respond, without confronting the spouse
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor
should the nurse include in the nursing problem "Imbalanced nutrition: more than body requirements"? -
ANSWERS LATEST VERSION WITH GREAT
RATIONALES GRADED A+
A client is receiving atenolol (Tenormin) 25 mg PO after a MI. The nurse determines the client's apical pulse is 65 bpm. What
action should the nurse implement next? -
✔️Administer the medication
Apical pulse is >60 bpm
The nurse is assessing a client and identifies a bruit over the thyroid. This finding is consistent with which interpretation? -
✔️Hyperthyroidism
enlargement of the thyroid gland (AKA goiter). Bruit may be auscultated d/t increase in glandular vascularity which increases as
it becomes hyperactive.
A 6-year-old child is alert by quiet when brought the the ER with periorbital ecchymosis and ecchymosis behind the ears. The
nurse suspects potential child abuse and continues to assess the child for additional manifestations of a basilar skull fracture.
What assessment finding would be consistent with a basilar skull fracture? -
✔️Rhinorrhoea or otorrhoea with Halo sign
Raccoon eyes (periorbital ecchymosis) and Battle's sign (ecchymosis behind the ears over mastoid process) are both signs of a
basilar skill fracture. Nurse should assess possible meningeal tear that manifest as a Halo sign with CSF leakage from ears or
nose.
The nurse is assessing a client who complains of weight loss, racing heart rate, and difficulty sleeping. The nurse determines
the client has moist skin with fine hair, prominent eyes, lid retraction, and a staring expression. These findings are consistent
with which disorder? -
✔️Grave's Disease
Aka hyperthyroidism; an autoimmune condition
The nurse is assessing an older client and determines that the client's left upper eyelid droops, covering more of the iris than
the right eyelid. Which description should the nurse use to document this finding? -
✔️Ptosis on the left eyelid
Ptosis = eyelid droop covering large portion of the iris. May result from oculomotor nerve or eyelid muscle disorder.
The nurse is assessing a child's weight and height during a clinic visit prior to starting school. The nurse plots the child's weight
on the growth chart and notes that the child's weight is in the 95th percentile for the child's height. What action should the nurse
take? -
✔️Question the type and quantity of foods eaten in a typical day
Daily diet needs to be assessed because child is overweight
The nurse obtains the pulse rate of 89 beats/minute for an infant before administering digoxin (Lanoxin). Which action should
the nurse take? -
✔️Withhold the medication and contact the healthcare provider
bradycardia is an early sign of digoxin toxicity. Infant HR <100 bpm, then withhold med and notify HCP.
The nurse is developing a teaching plan for an adolescent with a Milwaukee brace. Which instruction should the nurse include?
-
✔️Wear the brace over a t-shirt 23 hours per day
Idiopathic scoliosis is an abnormal lateral curvature of the spine in adolescent females. Milwaukee brace places pressure
against the lateral spine curvature, under the neck, and against the iliac crest. Wear 23 hrs/day over t-shirt which reduces
friction and chafing.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, "Why do you have to
wear a gown and mask when you are in my room?" How should the nurse respond? -
✔️"To protect you because you can get an infection very easily"
Reverse isolation precaution implement measures to protect the client from exposure to microorganism from others.
The nurse is giving discharge instructions to the parents of a newborn with a prescription for home phototherapy. Which
statement by a parent indicates understanding of phototherapy? -
✔️"I will keep the baby's eyes covered when the baby is under the light"
Neonatal jaundice is r/t subq deposition of fat-soluable (indirect) bilirubin, which is converted to a water-soluble form when the
skin is exposed to an ultraviolet light, so the infants eyes should be protected by closing the eyes and placing patches over
them before placing the baby under the light source.
, HESI COMPREHENSIVE 1 124 QUESTIONS AND
ANSWERS LATEST VERSION WITH GREAT
RATIONALES GRADED A+
A male client who had abdominal surgery has a nasogastric tube to suction, oxygen per nasal cannula, and complains of dry
mouth. Which action should the nurse implement? -
✔️Apply a water-soluble lubricant to the lips, oral mucosa and nares.
Will ease discomfort and keep the mucous membranes moist.
Petroleum-based is flammable DO NOT USE
The nurse is assessing the laboratory results for a client who is admitted with renal failure and osteodystrophy. Which findings
are consistent with the client's clinical picture? -
✔️Serum potassium of 5.5 mEq and total calcium of 6 mg/dl
In renal failure, normal serum electrolyte balance is altered because the kidneys fail to activate vit d, calcium absorption is
impaired, and serum calcium decreasesm which stimulates release of PTH causing resorption of calcium and phosphate from
the bone.
Which information should the nurse give a client with chronic kidney disease (CKD)? -
✔️Avoid salt substitutes
CKD pts should restrict sodium & potassium intake. Salt substitutes usually contain potassium (so, avoid!)
A nurse is anwsering questions about breast cancer at a hospital-sponsored community health fair. A woman asks the nurse to
explain the use of tamoxifen (Nolvadex). Which response should the nurse provide? -
✔️This anti-estrogen drug inhibits malignancy growth
tamoxifen (Nolvadex) is used in postmenopausal women with breast cancer to prevent and treat recurrent cancer and inhibit
the growth-stimulating effects of estrogen by blocking their receptor sites on malignant cells. Use for women with estrogen
receptor-positive breast cancer (not all women)
A 56-year-old female client is receiving intracavitary radiation via a radium implant. Which nurse should be assigned to care for
this client? -
✔️A nurse with Marfan's syndrome who is postmenopausal
Poses a radiation hazard while source is in place. Marfan's is not effected. Goal is to limit any one staff member's exposure to
the calculated time span based on the half-life of radium, such as the number of minutes at the bedside per day
Which information should the nurse provide a client who has undergone cryosurgery for Stage 1A cervical cancer? -
✔️Use a sanitary napkin instead of a tampon
Avoid use of tampons for 3-6 weeks after procedure to reduce risk of infection. Heavy watery vaginal discharge is expected.
Avoid sex up to 6 weeks
Which nurse follows a client from admission through discharge or resolution of illness and coordinates the client's care between
healthcare providers? -
✔️Case Manager
role is to assist the continuum of care for the client, & coordinate the plan of care, evaluate client needs & collaborate with
interdisciplinary HC team to ensure goals are met, quality is maintained, and progress toward discharge is made.
The nurse is preparing a client for a scheduled surgical procedure. What client statement should the nurse report to the HCP? -
✔️Recalls drinking a glass of juice after midnight
Risk of aspiration while under GA is increased when stomach is not empty prior to surgical procedure.
The parents of a 14-year-old boy express concern about their son's behavior, which ranges from clean-cut and personable to
"grungy" and sullen. They have tried talking with him and disciplining him, but he continues to demonstrate confusing
behaviors. Which information is best for the nurse to provide? -
✔️Early adolescence is a developmental state of normal experimentation
Support parents about the stage spurred by hormonal increases in pubescence and teenage experimentation with values,
choices, and peer acceptance.
The nurse is interviewing a female client whose spouse is present. During the interview, the spouse answers most of the
questions for the client. Which action is best for the nurse to implement? -
✔️Ask the spouse to step out for a few minutes
this maintains the client's privacy and allows the client to respond, without confronting the spouse
The nurse determines that a client's body weight is 105% above the standardized height-weight scale. Which related factor
should the nurse include in the nursing problem "Imbalanced nutrition: more than body requirements"? -
